Democrats are embracing a radical change to US healthcare, and it could be the defining political fight for years to come

Democrats are increasingly supporting "Medicare for All" - a
single-payer healthcare system championed by Sen. Bernie Sanders
and the progressive wing of the party.

President Donald Trump and the GOP are beginning to attack
the proposal - perhaps a sign of its political salience.

But it remains unclear exactly what version of Medicare for
All Democrats support, and it remains to be seen how politically
feasible the policy is.

President Donald Trump agrees with Democrats on a key political
reality: the importance of healthcare to the American voter.

Both Democrats and Republicans have zeroed in on the issue ahead
of the 2018 midterms. Republicans are attempting to quell concern
over the dismantling of Obamacare, insisting they support
protecting individuals with preexisting conditions (while
fighting those very same protections in court). Democrats are
increasingly backing the transformation of the insurance market
into a single-payer system, also known as "Medicare for All."

In a sign of Medicare for All's political salience, Trump this
week penned
a rare op-ed slamming the progressive proposal, calling it
the first step toward socialism and falsely accusing Democrats of
plotting to "eviscerate" Medicare and hurt seniors - a key voting
bloc.

Democrats embrace Medicare for All

In a signal of the shifting parameters in the healthcare debate,
former President Barack Obama endorsed Democratic calls for
Medicare for All in a speech in Illinois in September.

"Democrats aren't just running on good old ideas like a higher
minimum wage, they're running on good new ideas like Medicare for
All," he said.

While the term is newly ubiquitous, the concept of universal
public health insurance has had support in the US for more than a
century, although its popularity and perceived political
feasibility has fluctuated over time.

In 1994, then-first lady Hillary Clinton predicted that the US
would have a single-payer system by the year 2000. But by 2016,
Clinton's views had shifted. Framing herself as a pragmatic
centrist in her presidential primary against Vermont independent
Sen. Bernie Sanders, Clinton promised to improve Obamacare but
dismissed the single-payer system Sanders ran on as politically
impossible, arguing that it would "never, ever come to
pass."

A year ago, Sanders introduced his "Medicare for All" bill, which
would expand the popular government benefit into a health
insurance program for all Americans, rather than just those over
65.

Marking a shift in the Democratic Party, 15 other senators - many
of them on the unofficial list to run for president in 2020 -
signed on to the bill. More than 120 Democratic House members
support the lower chamber's nearly identical version of the bill.

The leading Medicare for All idea

While there are multiple Medicare for All bills in Congress, the
leading model is Sanders', in which there would be no private
insurance plans, Medicaid, or other government health plans, but
instead a single, nationally-run health insurance program.

Under the current system, consumers pay a monthly premium to a
private insurer which in turn pays doctors and healthcare
providers when a consumer receives care. Patients on private
plans and some government plans are also expected to pay
deductibles, an annual out-of-pocket amount, before insurance
kicks in, and co-pays, an out-of-pocket cost that splits the
price of care with the insurer.

Medicare for All
would do away with all of those payments, instead
creating a new tax for both employers and households as well
as bumping up some existing taxes to help fund payments. The
program would also redirect all current federal funds spent on
Obamacare insurance premiums and other federal healthcare
programs to the new program.

Doctors and healthcare providers would receive reimbursement
from the government at a rate set by the Department of Health and
Human Services.

Sanders' plan would set those reimbursement rates at the
current Medicare levels, which are typically much lower than what
healthcare providers receive from private insurers.

The program would also do away with what is known as balance
billing, which allows providers to directly charge the patient
the
difference between their reimbursement and their estimated
cost for providing a service.

To implement Sanders' Medicare for All plan:

The government would first expand the current Medicare
benefits to include types of care currently not covered, like
vision and dental.

Then the age of eligibility for Medicare would drop every
year over the course of four years until all Americans qualify.

Newborns would be automatically enrolled in the program.

Sanders' plan involves the most wholesale overhaul of the
healthcare system, but is not the only idea Democrats are
floating. Other members of Congress have proposed plans that
would create a federal option for people of all ages to purchase
a federally backed health insurance plan similar to Medicare or
Medicaid. This plan would not replace private insurance, but
rather act as another option alongside private coverage.

Everyone loves Medicare

A recent
Reuters/Ipsos poll found that 85% of Democrats, 52% of
Republicans, and 70% of Americans, overall, are in favor of
Medicare for All.

Nearly 60% of Americans favor a national health plan in which
Americans would be insured by the government, according to
a March poll conducted by the
nonpartisan Kaiser Family Foundation.

And when the policy involves a
public option with the ability to keep a private plan, support
for the proposal jumps to 75% (including 64% of
Republicans).

New York congressional candidate Alexandria Ocasio-Cortez ran and won her Democratic primary on a platform that included Medicare for All.Scott Eisen/Getty Images

Medicare's strong brand is likely a reason why the proposal is so
popular. Polling by the progressive policy group Data for
Progress found that
support jumps from 51% to 60%
when the term Medicare for All is used, rather than single-payer,
to describe a universal healthcare system.

" Americans tend to dislike
the idea of big government, but they like specific big government
programs. By tying universal healthcare to popular programs like
Medicare and Medicaid, progressives can build support for a
massive expansion of the social safety net," Data for Progress
cofounder Sean McElwee told Business Insider.

In a testament to Medicare's popularity, Republicans are
attacking Medicare for All by arguing the plan would "raid
Medicare to pay for socialism," as Trump
put it during an August rally.

Conservatives and other opponents of the proposal raise a host of
issues with the plan. The most cited objections are cost,
reimbursement rates for providers, the potential for healthcare
"rationing" or longer wait times for care, and the potential
stifling of pharmaceutical experimentation.

Given the variety of versions of Medicare for All, it's clear
Democrats are not quite on the same page when it comes to
defining the policy.

Single-payer proponents argue the party shouldn't compromise in
their quest to transform the healthcare system, while more
cautious Democrats want to avoid a political minefield that could
threaten candidates in competitive races and save a debate over
the details for later.

Adam Gaffney, a physician and instructor at Harvard Medical
School who supports both the House and Senate versions of
Medicare for All legislation, fears that "more establishment
types in the Democratic Party" will ultimately water the proposal
down into "something unrecognizable."

"Obstacle number one is the corporate opposition, obstacle number
two is the potential that Medicare for All could be co-opted or
sort of mutated into a lesser thing," Gaffney told Business
Insider.

Kara Eastman, a Medicare for All-supporting progressive running
for a US House seat in Nebraska, argued that voters of all
political persuasions are "craving authenticity and integrity" on
the ballot this year, and that candidates should be clear about
where they stand.

"Whether things are politically feasible right now - I don't
think that should stop a candidate from laying out a vision for
what we stand for and what we believe in," Eastman told Business
Insider.

Other supporters of single-payer argue that Democrats should
stake out an aggressive position on Medicare for All in part
because no matter what they support, Republicans will accuse them
of ushering in socialism, raising trillions in taxes, and
stripping seniors of care.

Indeed, the attacks against Democratic candidates in swing and
conservative districts have been fierce.

Rep. John Culberson, a Texas Republican, recently released an
ad claiming that his Democratic opponent, Lizzie Pannill
Fletcher, "supports a complete government takeover of health
care," despite the fact that Fletcher has specifically denounced
single-payer and supports "universal health care" achieved by
reforming Obamacare.

Running on Medicare for All

Progressive Democrats are running and winning on Medicare for All
across the country, in deep-blue, urban districts in the Bronx
and red states like Nebraska.

In fact, 20% of the Democratic Congressional Campaign Committee's
"Red to Blue" candidates support Medicare for All, according to
Rep. Pramila Jayapal, a Washington Democrat who founded a
Medicare for All PAC last month.

Meredith Conroy, an associate professor of political science at
California State University, San Bernardino, and a senior adviser
at Data for Progress, found that more than half of Democratic
candidates in open primaries this year with policy positions on
their campaign websites express support for Medicare for All.

"The majority of candidates included a 'healthcare' section
in on their issues page, and most discussed whether they support
Medicare for All," Conroy told Business Insider.

But a good portion of the Democratic Party remains unconvinced
that single-payer is politically feasible. They say that the
issue can help Democrats win primaries, but it will hurt them in
general elections - and they doubt a majority of Americans will
ever support the elimination of the private health insurance
market, even if Democrats amass the votes in Congress to pass it.

One Democratic congressional strategist pointed to Katie Porter
and Eastman, both Democratic candidates running on Medicare for
All who won their primaries in red districts (Orange County,
California, and urban/suburban Nebraska, respectively), as "test
cases." He argued that both candidates will face unnecessarily
brutal - and effective - attacks from their Republican opponents
on the issue.

"You're telling these people you're going to raise their taxes
and kick them off their employer plan to put them on some
government-run plan that they're not going to be nearly as happy
with," the strategist told Business Insider. "I think that's a
pretty salient line of attack."

But Porter insists that even in Orange County, where wealthy
residents might be largely satisfied with their current plans,
the system ultimately fails even the wealthiest.

"You simply can't save sufficient wealth and you can't buy
sufficient insurance to cover the cost of a severely premature
baby or to cover the cost of a long-term chronic cancer
condition," Porter told Business Insider.

Eastman says she's challenged some of her more affluent potential
constituents to consider the systemic benefits of single-payer.

"Today I had somebody tell me he felt lucky that he had such good
coverage through his employer, and my response to him was to say,
'Yes, and do you think it's fair for you to be lucky enough to
have that coverage when so many other people do not have that
kind of luck?'" Eastman said. "He was fairly stymied by that
question."